Navigating Medicare Policy on Physical Therapy and Other Services

For years, some people on Medicare had difficulty getting insurance coverage approved for physical therapy, occupational therapy and other treatments. The prevailing approach was that if the therapy was not helping to improve a patient’s condition, then it was not eligible for coverage.

“They’d get denied because they weren’t improving, or because they had plateaued,” said Judith Stein, executive director of the Center for Medicare Advocacy, a nonprofit consumer group. The situation was especially difficult, she said, for patients with chronic or degenerative conditions, like Parkinson’s disease or multiple sclerosis.

That is changing, as a result of a 2013 settlement of a lawsuit that the center and others brought against the secretary of the Health and Human Services Department, the parent agency of the Centers for Medicare and Medicaid Services, which oversees Medicare. The suit claimed that Medicare billing contractors were inappropriately denying coverage for “skilled” care by applying an “improvement” standard as a rule of thumb.

Because of the settlement, the agency updated its policy manuals last year. The revisions make clear that if treatment is needed to prevent or slow further deterioration in a patient’s condition, “coverage cannot be denied based on the absence of potential for improvement or restoration.” The update applies to therapy provided in nursing homes, in outpatient clinics and at home. (The agency maintains that the revision was not a change, but was made to “clarify” what had been existing Medicare policy.)

However, Ms. Stein said, the center is still hearing from patients who say they are facing hurdles in getting maintenance treatment. “A lot of providers don’t know about the change,” she said, or they remain skeptical that such care will be covered.

David Weiman said his 92-year-old mother, Roschelle Paul Weiman, a one-time jazz singer, was receiving outpatient physical therapy in San Francisco to help with her gait and mobility, and to reduce pain. “It helped me tremendously,” Mrs. Weiman said in a brief telephone interview.

But in March, she was told her therapy would be discontinued because she had “plateaued,” Mr. Weiman said. His mother later read about the revision to Medicare’s policy, and asked her son to intervene on her behalf. Mr. Weiman contacted her physical therapy provider and supplied Medicare’s revised language, he said; she is now resuming treatment. “Somewhere between Medicare and the providers,” he said, “there’s a keen lack of knowledge.”

The Centers for Medicare and Medicaid Services says that in January the agency completed an “extensive” educational campaign, as required by the settlement, including national conference calls for claims adjudicators and therapy providers.

However, perhaps the federal government may need to do more to educate therapists and Medicare contractors about coverage of maintenance care, Ms. Stein said.

Here are some additional questions about Medicare coverage for maintenance care:

■What if my provider won’t continue treatment, or if my claim for coverage under Medicare is denied, for nonimprovement reasons?

You can refer your provider to the centers’ website, which describes the new approach. If necessary, you can appeal, using the process outlined on your Medicare statement; Ms. Stein suggests attaching copies of the updated policy.

■What if I was improperly denied coverage, before the clarification was issued?

You may qualify to have your claim “re-reviewed,” if you were denied coverage based on your lack of potential to improve. The process isn’t automatic, though; you must apply. You can seek a re-review if your claim became final — meaning, Medicare denied your claim, and it wasn’t eligible for any more appeals — between Jan. 18, 2011, and before Jan. 23, 2014. (That means you may have received the actual treatment earlier, according to California Health Advocates.)

There are two deadlines for applying, and the first is coming up this summer. If your claim became final between Jan. 18, 2011 and Jan. 24, 2013, you must file the request by July 23. (If your claim was final between Jan. 25, 2013, and Jan. 23, 2014, you have until Jan. 23 of next year to file)

A questionnaire to help you determine if you’re eligible for re-review, and the form to submit, is available on the website of the Centers for Medicare and Medicaid Services.

■Where can I get additional information about the revised policy and how it may apply to my situation?